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Primary Care Provider (PCP) Rules - Overview

1. Purpose​

This service helps organizations understand the guidelines for assigning a Primary Care Provider (PCP) during the setup of new health plan enrollments. It provides high-level information about plan categories and state-specific rules to ensure members are linked to the right PCP, supporting coordinated care and compliance.

2. Who can use this service​

  • External Partners & Integrators: Brokers, aggregators, and enrollment platforms working with UnitedHealthcare.
  • Employers & Benefits Administrators: Organizations setting up employee coverage and needing PCP assignment context.
  • Healthcare Solution Providers: Teams building tools or portals that support plan setup and member onboarding.

3. What information is available​

  • State Guidelines: Broad rules for PCP assignment based on location.
  • Plan Categories: Which types of plans allow automatic PCP assignment versus manual selection.
  • Eligibility Indicators: Key criteria pertaining to coverage requirements and provisions for coordinated care.
  • General Data Types: Examples include plan characteristics, coverage considerations, and demographic factors (no technical details or schema exposed).

4. Benefits of this service​

  • Streamlined Enrollment: Reduces guesswork by providing clear PCP assignment rules upfront.
  • Compliance Support: Ensures adherence to state and product-level requirements.
  • Improved Member Experience: Guides members toward correct PCP relationships without confusion.
  • Operational Efficiency: Minimizes back-and-forth during onboarding and reduces integration issues.

5. Example uses​

  • Broker Onboarding: A broker checks state PCP rules for a client’s chosen plan to configure enrollment flows correctly.
  • Enrollment Portal Design: An aggregator determines whether to show an “automatic assignment” option or a “choose your provider” option based on plan type.
  • Member Communication: A partner references general plan categories and coordinated care notes for welcome materials.
  • Case Installation Logic: An integrator uses high-level rules to branch business logic (e.g., coordinated care steps for certain plans).

6. Important notes​

  • This summary omits all technical details, authentication steps, API endpoints, error codes, and proprietary schemas.
  • Information provided is conceptual and subject to change as plans or state guidelines evolve.
  • For implementation details, partners should consult secure technical onboarding resources.
  • All trademarks and proprietary rights remain with their respective owners.
  • This Is an Overview: Technical specifications and operational details are provided separately through partner-only channels.